Prescription Benefit Summaries: HMO/POS/DPOSGroups 100+

Standard | Select | Deductible/Coinsurance

Forms are in pdf format.

Option
$0
$1
$1/$3
$2/$6
$3/$5
$4/$8
$5
$5/$20
$6/$10
$8/$14
$10
$10/$15
$10/$20
$15
50%
$4 Generic/Brand Discount HMO Standard Drug
$7 Generic/Brand Discount HMO Standard Drug
$7/50%/$125 Max HMO Standard Drug
$7 Generic/50% with $250 Max Brand HMO Standard Drug